This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
Following a comprehensive review of supporting clinical research and recommendations from the North Carolina Physician Advisory Group (NCPAG), NC Medicaid intends to further amend its clinical criteria for Wegovy and Zepbound to more closely align with the U.S. Food and Drug Administration (FDA) indications and usage for each drug.
Key Coverage Changes
Effective immediately, the NC Medicaid Outpatient Pharmacy Prior Approval Criteria for GLP-1s – Wegovy and Zepbound clinical criteria is being removed from the NCTracks Pharmacy Prior Approval Drugs and Criteria website.
Until the revised clinical criteria for Wegovy and Zepbound are promulgated in accordance with NCGS § 108A-54.2(b)(2), NC Medicaid will cover Wegovy and Zepbound for clinical indications other than weight loss based on the FDA-approved indications and uses, which include:
- Reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight.
- Treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis in adults.
- Treatment of moderate to severe obstructive sleep apnea in adults with obesity.
Important Reminder
Effective Oct. 1, 2025, NC Medicaid no longer covers Wegovy and Zepbound solely for the treatment of obesity, as indicated in the NC Medicaid to Change Coverage for GLP-1 Weight Management Medications bulletin.
Contact
NCTracks Call Center: 800-688-6696